The DRAM, Vol. 20(9) – Beyond the scale: Exploring alcohol use in Anorexia Nervosa

Anorexia Nervosa (AN) is a severe eating disorder marked by an intense fear of gaining weight and distorted body image, leading to extreme calorie restriction and drastic weight loss. It is common for people with eating disorders to also struggle with Alcohol Use Disorder (AUD). They may use alcohol as a means of managing depressive symptoms and obsessive thoughts about body image and weight. However, the specific association between AN and AUD is less clear, compared to other eating disorders like Bulimia Nervosa. This week, The DRAM reviews a study by Zara Smalley and colleagues that investigated the differences in alcohol-related behaviors among individuals with acute AN, those recovered from AN, and healthy controls, while also exploring the connections among alcohol-related behaviors, eating disorder psychopathology (i.e., distress associated with one’s weight, shape, eating, and other related factors), and depression across these groups.

What were the research questions?
(1) How do people with acute AN, people in recovery from AN, and healthy controls differ in terms of alcohol-related behaviors (i.e., alcohol consumption, dependence, and alcohol-related problems) that might contribute to the development of AUD? (2) Is there a link among eating disorder psychopathology, alcohol-related behaviors, and depression?

What did the researchers do?
The researchers conducted a secondary analysis using data from a cross sectional study conducted in 2018. They used convenience sampling to recruit 140 female participants over the age of 18 and separated them into three groups: those diagnosed with acute AN, those in recovery from AN, and a healthy control group. Participants completed questionnaires about demographic factors, eating disorder psychopathology¹, alcohol-related behaviors, and depression symptomatology². To measure alcohol-related behaviors, they used the Alcohol Use Disorders Identification Test (AUDIT), which provides an overall score as well as scores on 3 components: alcohol consumption, alcohol dependence, and alcohol-related problems. They explored differences in alcohol-related behaviors, accounting for age and ethnicity. The researchers also used Spearman rank correlation coefficient to examine the relationships among eating disorder psychopathology, alcohol use, and depression.

What did they find?
The acute AN, recovered AN, and healthy control groups experienced significant differences in alcohol consumption, alcohol-related problems, and total AUDIT scores. They were similar in terms of alcohol dependence (see Figure). Interestingly, specific comparisons revealed that those in recovery from AN reported greater alcohol consumption and alcohol-related problems than those still experiencing AN. All groups, however, had mean AUDIT scores less than 7, indicating low overall risk, because scores of 20-40 indicate a high likelihood of alcohol dependence. Correlation analysis revealed a positive association only in the healthy control group, where higher alcohol dependence and related problems were associated with higher eating disorder psychopathology scores and body shape concerns as well as depressive symptoms.

Figure. Mean scores of the AUDIT subscales and total AUDIT scores across three groups: acute AN, recovered AN, and the healthy control group. Higher scores indicate greater likelihood of harmful alcohol use. * indicates statistical significance at the 0.05 level. Click image to enlarge.

Why do these findings matter?
These findings shed light on the nuanced relationships between AN and alcohol use. For example, the study highlighted that individuals who recovered from AN exhibited relatively high levels of alcohol consumption and related problems. This suggests that recovery from AN may make individuals vulnerable to alcohol-related issues. Perhaps people with acute AN might be more reluctant to drink alcohol because of its high calorie content. Additionally, the finding that groups maintained low-risk AUDIT scores suggests that while alcohol use is present, it has not typically reached problematic levels. This finding emphasizes the need for ongoing screening and prevention strategies to mitigate future risks. Furthermore, the positive associations between alcohol dependence and eating disorder psychopathology among healthy controls suggests that negative body image may contribute to increased alcohol use as a coping mechanism. Understanding these dynamics is crucial for developing comprehensive treatment plans that address both eating disorder psychopathology and co-occuring issues like alcohol use and depression.

Every study has limitations. What are the limitations in this study?
Participants from ethnically minoritized backgrounds were overrepresented in the control group, particularly those of Asian descent who may have had certain genetic effects that could have influenced alcohol-related outcomes. Similarly, the lack of diversity in the acute AN and recovered AN groups made it difficult to generalize the findings to males and other ethnicities.

For more information:
The National Alliance on Mental Illness or NAMI offers resources for individuals dealing with eating-related mental health symptoms. The National Institute on Alcohol Abuse and Alcoholism has tips and resources for people struggling with problem drinking. For additional drinking self-help tools, please visit our Addiction Resources page.

— Nakita Sconsoni, MSW
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1. The Eating Disorder Examination-Questionnaire (EDE-Q)
2. The Beck Depression Inventory (BDI-II)